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Dr. Amy Tung, ND - Menopause and Cardiovascular Risk: What Every Woman Should Know

During a woman's reproductive years, estrogen plays a vital protective role: it helps keep blood vessels flexible (through the action of nitric oxide), controls inflammation, and promotes a healthy cholesterol profile. After menopause, the loss of estrogen removes this protection, putting women at higher risk for hypertension, high cholesterol, atherosclerosis, and increased central body fat often referred to as "meno-belly".

“Estrogen provides a protective effect against heart disease in women. Therefore, the risk of CVD increases after menopause in most cases. Men develop heart diseases earlier than women because of the protection in the reproductive phase of their life. Once they enter menopause the risk increases.” (Ryczkowska et al., 2022).​

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death among women. In fact, ASCVD  risk increases rapidly in menopausal women due to a unique blend of conventional risk factors as well as female-specific risk factors. Understanding these risks is crucial for effective prevention, especially as menopause marks a critical time of increased vulnerability to heart disease and stroke.​

ASCVD (Atherosclerotic Cardiovascular Disease) includes a group of conditions caused by atherosclerosis—the buildup of plaque in arterial walls—which leads to reduced or blocked blood flow. The main conditions included under ASCVD are:

- Coronary artery disease (CAD): Includes myocardial infarction (heart attack), angina (chest pain), and any history of coronary re-vascularization (bypass surgery or stenting)
- Cerebrovascular disease: Includes ischemic stroke and transient ischemic attack (TIA) caused by atherosclerotic plaque in the arteries supplying the brain
- Peripheral artery disease (PAD): Narrowing or blockage of arteries outside the heart and brain—most commonly in the legs, leading to symptoms like claudication (pain on walking)

In summary, ASCVD includes:

- Myocardial infarction (MI commonly known as a heart attack)
- Angina pectoris
- Coronary artery disease (CAD)
- Ischemic stroke
- Transient ischemic attack (TIA)
- Peripheral artery disease (PAD)
- Aortic atherosclerotic disease (often included under ASCVD umbrella)

These conditions are all related by their underlying cause: atherosclerotic plaque buildup in the arteries.

## Understanding ASCVD Risk

ASCVD risk involves factors that can impact heart and blood vessel health. Risk factors for both men and women:

- Hypertension/high blood pressure (normal pressure is 120/80)
- Smoking or vaping
- Elevated triglycerides
- Elevated Apo B tagged molecules (see below for more info on what Apo B molecules are)
- Insulin resistance, prediabetes, diabetes
- Genetics, e.g. familial hypercholesterolemia (FH), ApoE4 carriers, elevated Lipoprotein (a)

Smoking accelerates arterial damage and interacts with lower estrogen to create a dangerous synergy, greatly amplifying ASCVD risk.​

Blood pressure measures the force of blood against artery walls. High blood pressure, or hypertension, forces the heart to work harder, potentially leading to heart disease or stroke.

High blood pressure is more common after menopause due to the loss of estrogen’s vasodilatory protection from the endothelial nitric oxide (NO). Women are less likely to achieve target blood pressure, increasing the risk of heart attack and stroke.​

## Role of Apolipoprotein B and Lipoprotein(a) in ASCVD

Traditional cholesterol testing (LDL, HDL, total cholesterol) provides useful information, but newer markers give a clearer picture of cardiovascular risk after menopause. Apolipoprotein B (Apo B) is a protein present on all atherogenic lipoprotein particles and reflects the number of cholesterol-rich particles circulating in your blood.

Apo B tagged molecules include all the ones listed below, and all of these molecules can become oxidized in the endothelial lining and lead to inflammation and subsequent plaque formation.

- Low-density lipoprotein (LDL)
- Very Low density lipoprotein (VLDL)
- Intermediate Dense Lipoprotiens (IDLs)
- Chylomicron remnant
- Lipoprotein(a) (Lp(a))

Apo B tagged molecules have only  one Apo B Apolipoprotein tag per molecule. Why this is important, is that it allows us to know the number of particules that have the potential to become atherogenic.

It therefore gives us a very good indication of how many actual potentially atherogenic or "bad" molecules there are in the body. Apo B blood test levels therefore can tell us an individual's overall risk for developing ASVD, better then just LDL-C alone.

"Elevated Apo B indicates a high concentration of particles that can contribute to atherosclerosis, making it a more sensitive marker than LDL alone for cardiovascular risk, especially in postmenopausal women." (Boffa & Koschinsky, 2024)

Lipoprotein(a)-Lp(a) is a genetically determined lipid particle with pro-inflammatory and pro-thrombotic (clot forming) properties. High levels of Lp(a) are a powerful, independent risk factor for coronary artery disease and stroke in postmenopausal women. Lp(a) levels are inherited and are not influenced by diet or lifestyle changes.

Studies confirm that Lp(a) increases after menopause, compounding the higher risk observed in women compared to men. You should be tested for Lp(a) levels at least once in your life to know your status. If you have not ever been tested, speak to your primary care provider.

## Unique ASCVD Risk Factors in Menopausal Women

The most common risk factors such as hypertension, diabetes, obesity, and high cholesterol become more prevalent or can worsen with menopause.​ Menopause triggers a cascade of complex hormonal, metabolic, and physiological changes that heighten ASCVD risk. 

The decline and l oss of estrogen during the menopausal transition leads to negative changes in cholesterol, blood vessel function, and fat distribution.​ In fact, menopausal symptoms, such as hot flashes and night sweats, have been linked to increased blood pressure and higher ASCVD risk.​

## ASCVD Risk Factors  Unique to Women

- Age of Menarche (Early menarche ≤10 years and late menarche after 17 yoa)
- Early Menopause (<45) and Menopause
- Parity (lowest risk 2 births, highest risk ≥5 births)
- Gestational Diabetes
- Pre-Eclampsia
- Polycystic Ovarian Syndrome (PCOS)
- Autoimmune Disease (e.g. Lupus, Rheumatoid Arthritis, etc.)
- Premature Ovarian Insufficiency (POI)
 (McKibbin, et al., 2015)

Addressing, and treating these factors early can dramatically reduce the long-term burden of cardiovascular disease.

## Optimal Lab Values for Menopausal Women

## Apolipoprotein B

Clinical guidelines increasingly highlight that lower ApoB is better, especially as ApoB is a more sensitive marker for ASCVD risk than LDL alone. Major societies, including Canadian and European guidelines, recommend aiming for ApoB <80 mg/dL for most and <60–70 mg/dL for those at highest risk.

## Lipoprotein (a) or Lp(a)

In Canadian labs, Lp(a) is reported as either mg/dL or nmol/L. Some debate is ongoing, but the recommended measurements are in nmol/L as this tells us the number of molecules of Lp(a) are present and is a better representation of risk then mg/dL. Most labs now use nmol/L. Check the lab that you are using however.  The optimal range is below 75 nmol/L and above 125 nmol/L is always considered high.

## Cholesterol Panels (LDL, HDL, non-HDL), Triglycerides & TG/HDL ratio

Ideal LDL-C <2.0 mmol/L for most adults (US range <100 mg/dL), while HDL-C can vary however women generally ~1.0 mmol/L (is considered low), and 1.3–1.5 mmol/L (is considered average/good) and can go up to 2.2 mmol/L (upper range). Having levels higher then 2.2mmol/L may have no additional benefit.

Optimal triglycerides for lowest cardiovascular risk is <1.0 but normal is < 1.5 mmol/L (US range< 150 mg/dL). Triglyceride as an independent risk factor for ASCVD and elevated triglycerides can be a sign of insulin resistance your primary care provider can also calculate a TG/HDL ratio to determine the level of insulin resistance. Optimal TG/HDL ratio is < 3.0.

## Fasting insulin, fasting blood glucose & HOMA-IR

One's fasting insulin and fasting glucose levels can be used to calculate a HOMA-IR score. HOMA-IR is the "Homeostatic Model of Assessment of Insulin Resistance". I want my patients <1.0 for their HOMA-IR. This means your body is using insulin effectively.

Based on these numbers, your health care team will determine the need for any interventions.

## Managing Cardiovascular Risk Through Prevention

Adopting healthy lifestyle changes can significantly reduce cardiovascular risk. This involves focusing on dietary habits, engaging in physical activity, maintaining a healthy weight, and quitting smoking.

As a Naturopathic Doctor (ND), I believe it is crucial for women to understand the profound changes menopause brings—not only in hormones but also in long-term heart health. The transition to menopause significantly increases the risk of ASCVD which is the leading cause of death among women as we age.

## Lifestyle Changes

Regular physical activity, a [Mediterranean diet](/med-diet/hormone-health) , weight management, eliminating or limiting alcohol, stress reduction, and high-quality sleep all lower ASCVD risk.​ Eating a variety of fruits, vegetables, and whole grains gives your body the nutrients it needs. Include foods rich in omega-3 fatty acids like fish, which are good for heart health. Aim for at least 150 minutes of moderate-intensity exercise each week, such as brisk walking, cycling, or swimming. This supports a healthy heart by improving circulation and helping to maintain a healthy weight.

## Smoking Cessation

Quitting smoking provides immediate and long-term cardiovascular benefits.​ The risk of smoking or vaping are detrimental to the endometrial lining of the arterial wall. The sooner someone quits, the better for their heart.

## Blood Pressure Management

Reducing salt intake, increasing potassium-rich foods, and regular monitoring are critical. Optimal BP for most people is around 120/80. If you have not had your blood pressure checked recently, I recommend you check this at least every few months, and if you have a history of high blood pressure that you make this a priority to manage.

## Targeted Supplementation: Vitamin D3 & Omega 3 EPA/DHA

It is important to speak to your Naturopathic Doctor to discuss the right supplements for you. Key nutrients such as Vitamin D3 may be important to supplement supports the use of certain supplements, such as omega-3 fatty acids for it's high EPA and DHA content for lipid lowering benefits. However, supplements must be individualized, considering potential drug interactions and overall health.​

## Dietary Fiber

Increasing soluble fiber from sources like psyllium husk fibre powder, chia seeds, ground flax seeds, oats, legumes, and fruits helps lower cholesterol and improve metabolic health. I recommend my patients aim for at least 10 grams and increase to 20 grams and ultimately aim for about 30 grams daily. Make sure to drink adequate water when increasing fibre. Aim for at least 2 L of water a day or more.

## Medications

For women at high risk or with existing ASCVD, statins, antihypertensives, or hormone replacement therapy (HRT) may be considered, always tailored to individual risk-benefit profiles.​ Medications such as statins remain the standard of care for treatment of high cholesterol and can greatly reduce ASCVD risk more then any other treatment alone.

HRT is not specific to reducing cholesterol levels, it is only indicated in some women who have underlying vasomotor symptoms such as hot flashes and night sweats or for the prevention of bone loss.

## Weight Management and Cardiovascular Risk

Weight management is vital when it comes to reducing cardiovascular risk. Being overweight or obese increases the risk of heart disease, high blood pressure, and diabetes. To maintain a healthy weight, focus on a balanced diet combined with regular exercise.

Losing 5-10% of body weight (especially visceral fat loss) can have a significant impact on insulin resistance as well as overall heart and ASCVD risk. Monitor your weight regularly to keep track of progress. By achieving and maintaining a healthy weight, you actively reduce the strain on your heart and improve overall health.

## Pharmaceutical Medications to Manage Cholesterol

Medications are central to controlling cholesterol and blood sugar levels. For cholesterol management, statins remain the standard of care for many patients.

e.g. Atorvastatin (Lipitor), Rosuvastatin (Crestor), Simvastatin (Zocor), Pravastatin (Pravachol), Fluvastatin (Lescol), Lovastatin (Mevacor), and Pitavastatin (Livalo)

Stains are commonly prescribed to lower LDL cholesterol, reducing the risk of heart attacks and strokes. Other classes of medications such as PCSK9 inhibitors, which help lower cholesterol levels significantly. These are especially valuable for patients who can't tolerate statins.

Other classes of drugs include: PKSK9 Inhibitors (e.g. (evolocumab, alirocumab), Ezetimibe, Bempedoic acid, Fibrates (fenofibrate, gemfibrozil) Antisense Oligonucleotides (pelacarsen, olpasiran – investigational) & CETP Inhibitors.

Pharmaceutical management is most effective when combined with lifestyle and nutraceutical interventions. The goal is not only to lower LDL cholesterol, but to reduce particle number (measured by Apo B and non-HDL), improve plaque stability, and modify disease biology.

## Pharmaceutical Medications for Diabetes Care

For diabetes, pre-diabetes and obesity, GLP-1 receptor agonists and SGLT2 inhibitors represent recent advancements that not only lower blood sugar but also offer cardiac benefits. These medications improve your heart health while managing diabetes, making them a dual-action therapy option.

Engaging with your health care team about these emerging therapies might help tailor a comprehensive treatment plan that addresses both cardiovascular risks and diabetes management effectively.

Poor insulin control as well as resulting imbalance blood sugar levels can damage blood vessels, leading to conditions such as heart disease and heart failure.  Diabetes is also a major risk factor for strokes. Managing your blood sugar and blood pressure can help prevent these serious complications. According to a study, complications can occur even in the absence of other diseases, highlighting the need for vigilant monitoring.

## Hormone Replacement therapy (HRT) and ASCVD risk

Hormone replacement therapy (HRT) remains an area of controversy when it comes to use for ASCVD prevention.  HRT may offer potential benefits for cardiovascular health, especially when started in the perimenopausal years or within 10 years of the final menstrual period. Safety with the use of transdermal estrogen (e.g. Estrogel or patches such as Estradot) with oral micronized progesterone verses oral conjugated equine oestrogen (CEE) plus medroxyprogesterone acetate (MPA) has been shown in multiple research followups since the Women's Health Initiative (WHI).

Oral CEE and MPA were the forms used in the famous WHI, which showed increased risk of stroke, heart attack and blood clot. Possible, improved blood vessel function, and r educed Insulin resistance resulting in overall improved weight loss. However, despite these potential benefits, HRT is not recommended for use for primary prevention of ASCVD.

The cardiovascular benefits are greatest when HRT is tailored to the individual—considering age, timing, and type of hormone used (transdermal estrogen is often preferred for lowest clot risk).  HRT when prescribed appropriately and at the right time in a woman’s life. This is a key reason HRT is considered for menopausal symptom management and long-term health protection.

Book a free discovery call with Dr. Amy [here](https://dramytung.janeapp.com/#/free-discovery-call).

To your best health,

Dr. Amy Tung, ND

Naturopathic Doctor

Menopause Society Certified Practitioner (MSCP)

## References:

Boffa, MB, & Koschinsky, ML. Lipoprotein(a) and cardiovascular disease. Biochem J 3 October 2024; 481 (19): 1277–1296. doi: https://doi.org/10.1042/BCJ20240037

Carson, J., Lichtenstein, A., Anderson, C., Appel, L., Kris-Etherton, P., Meyer, K., Petersen, K., Polonsky, T., & Van Horn, L. (2019). Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. , 141, e39 - e53. https://doi.org/10.1161/CIR.0000000000000743.

Kim, M., Han, K., Park, Y., Kwon, H., Kang, G., Yoon, K., & Lee, S. (2018). Associations of Variability in Blood Pressure, Glucose and Cholesterol Concentrations, and Body Mass Index With Mortality and Cardiovascular Outcomes in the General Population. Circulation, 138, 2627–2637. https://doi.org/10.1161/CIRCULATIONAHA.118.034978.

McKibben RA, Al Rifai M, Mathews LM, Michos ED. Primary Prevention of Atherosclerotic Cardiovascular Disease in Women. Curr Cardiovasc Risk Rep. 2016 Jan;10:1. doi: 10.1007/s12170-015-0480-3. Epub 2015 Dec 29. PMID: 28149430; PMCID: PMC5279938. https://pmc.ncbi.nlm.nih.gov/articles/PMC5279938/#S27

Morenga, L., Howatson, A., Jones, R., & Mann, J. (2014). Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids.. The American journal of clinical nutrition, 100 1, 65-79 . https://doi.org/10.3945/ajcn.113.081521.

Ruiz-Núñez, B., & Muskiet, F. (2016). The relation of saturated fatty acids with low-grade inflammation and cardiovascular disease.. The Journal of nutritional biochemistry, 36, 1-20 . https://doi.org/10.1016/j.jnutbio.2015.12.007.

Ting, K. (2024). John Yudkin’s hypothesis: sugar is a major dietary culprit in the development of cardiovascular disease. Frontiers in Nutrition, 11. https://doi.org/10.3389/fnut.2024.1407108.

Disclaimer:

The information in this blog is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of your doctor or other qualified health professional with any questions regarding a medical condition or treatment. Never disregard professional medical advice or delay seeking treatment because of something you have read in this blog.

Individual results may vary, and the strategies discussed here are not guaranteed to work for everyone. This content does not create a patient-client relationship and should not be used as a replacement for personalized medical care.

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